Farrohknia et al.

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:42

http://www.sjtrem.com/content/19/1/42

REVIEW

Open Access

Emergency Department Triage Scales and Their

Components: A Systematic Review of the
Scientific Evidence
Nasim Farrohknia1*, Maaret Castrn2, Anna Ehrenberg3, Lars Lind4, Sven Oredsson5, Hkan Jonsson6, Kjell Asplund7
and Katarina E Gransson8,9

Abstract
Emergency department (ED) triage is used to identify patients level of urgency and treat them based on their
triage level. The global advancement of triage scales in the past two decades has generated considerable research
on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for
published ED triage scales. The following questions are addressed:
1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within
30 days after arrival at the ED?
2. What is the level of agreement between clinicians triage decisions compared to each other or to a gold
standard for each scale (reliability)?
3. How valid is each triage scale in predicting hospitalization and hospital mortality?
A systematic search of the international literature published from 1966 through March 31, 2009 explored the British
Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to
controlled studies of adult patients (15 years) visiting EDs for somatic reasons. Outcome variables were death in
ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study
were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality
standards were synthesized applying the internationally developed GRADE system. Each conclusion was then
assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not
available, this was also noted.
We found ED triage scales to be supported, at best, by limited and often insufficient evidence.
The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all,
studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one
triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and
one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients
assigned to the two lowest triage levels on a 5-level scale (validity).
Introduction
Triage is a central task in an emergency department
(ED). In this context, triage is viewed as the rating of
patients clinical urgency [1]. Rating is necessary to identify the order in which patients should be given care in
an ED when demand is high. Triage is not needed if
* Correspondence: Nasim.farrokhnia@medsci.uu.se
1
The Swedish Council for Health Technology Assessment and Dep of
Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
Full list of author information is available at the end of the article

there is no queue for care. Triage scales aim to optimize

the waiting time of patients according to the severity of
their medical condition, in order to treat as fast as
necessary the most intense symptom(s) and to reduce
the negative impact on the prognosis of a prolonged
delay before treatment. ED triage is a relatively modern
phenomenon, introduced in the 1950s in the United
States [2]. Triage is a complex decision-making process,
and several triage scales have been designed as decisionsupport systems [3] to guide the triage nurse to a

2011 Farrohknia et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Farrohknia et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:42
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correct decision. Triage decisions may be based on both

the patients vital signs (respiratory rate, oxygen saturation in blood, heart rate, blood pressure, level of consciousness, and body temperature) and their chief
complaints. Internationally, no consensus has been
reached on the functions that should be measured.
Apart from emergency care, triage may be used in other
clinical activities, e.g. deciding on a certain investigation
[4] or treatment [5].
Since the early 1990s, several countries have developed and introduced ED triage [6-10]. Development of
triage scales in some countries has been influenced largely by the seminal work of FitzGerald [11], resulting
in most of the triage scales developed in the 1990s and
2000s being designed as 5-level scales. Of these, the
Australian Triage Scale (ATS), Canadian Emergency
Department Triage and Acuity Scale (CTAS), Manchester Triage Scale (MTS), and Emergency Severity Index
(ESI) have had the greatest influence on modern ED
triage [12-15]. Other scales have not disseminated as
widely around the globe, e.g. the Soterion Rapid Triage
Scale (SRTS) from the United States and the 4-level
Taiwan Triage System (TTS) [6,7,9,16,17]. Some countries, e.g. Australia, have a national mandatory triage
scale while many European countries lack such standards [7,9].
Patients may have a life-threatening condition, but
show normal vital signs. Hence, in triaging the patient it
is important to consider information given by patients
or accompanying persons regarding the patients chief
complaints or medical history, which can provide essential information about serious diseases. The chief complaints describe the incident or symptoms that caused
the patient to seek care.
In 2005, a joint task force of the American College of
Emergency Physicians and the Emergency Nurses Association published a review of the literature on ED triage
scales. Based on expert consensus and available evidence, the task force supported adoption of a reliable 5level triage scale, stating that either the CTAS or the
ESI are good choices for ED triage [18]. In 2002, a
national survey conducted in Sweden identified the use
of 37 different triage scales across the country. Further,
some 30 EDs did not use any type of triage scale [19].
This systematic review aims to investigate the scientific evidence underlying published ED triage scales.

Objectives
The following questions are addressed:
1. In triage of adults at EDs, does assessment of individual vital signs or chief complaints affect mortality
during the hospital stay or within 30 days after arrival at the ED?

Page 2 of 13

2. In adult ED patients, what is the level of agreement between clinicians triage decisions compared
to each other or to a gold standard for each scale (i.
e. the reliability of triage scales)?
3. In adult ED patients, how valid is each triage scale
in predicting hospitalization and hospital mortality?

Methods
A systematic search of the international literature published from 1966 through March 31, 2009 explored the
British Nursing Index, Business Source Premier,
CINAHL, Cochrane Library, EMBASE, and PubMed.
Inclusion was limited to studies of adult patients (15
years) visiting EDs for somatic reasons. Another criterion for inclusion was that the study design must contain
a control, i.e. randomized controlled trials (RCT), observational studies with a control group based on previously collected data, and before-after studies.
Descriptive studies without a control group and retrospective studies were excluded.
Inclusion criteria for vital signs and chief complaints used
in triage scales

Studies analyzing individual vital signs or chief

complaints
Outcome variable defined as death within 30 days
after ED arrival or during the hospital stay

Inclusion criteria for reliability and validity of triage scales

Studies based on real patients triaged at EDs

(validity)
Studies based on real patients triaged at EDs or fictitious patient scenarios (reliability)
Studies reporting reliability at separate triage levels
(reliability)
Studies reporting mortality and hospitalization per
triage level (validity)
Outcome variables defined as death in the ED or
hospital, and need for hospitalization (validity)

Exclusion criteria for studies on reliability of triage scales

Studies on interrater reproducibility are excluded

in cases where any rater in the study had access to
retrospective data only.
Six experts from different professions and clinical specialties reviewed the studies, independently in groups of
2 or 3, for quality by using methods validated for internal validity, precision, and applicability (external validity)
[20]. The methodological quality and clinical relevance
of each study was graded as high, medium, or low.
Results from the studies that met the inclusion criteria

Farrohknia et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:42
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and quality standards were synthesized by applying the

internationally developed GRADE system [21].
In accordance with GRADE, the following factors were
considered in appraising the overall strength of the evidence: study quality, concordance/consistency, transferability/relevance, precision of data, risk of publication
bias, effect size, and dose-response. In synthesizing the
data, studies having low quality and relevance were
included when studies of medium quality and relevance
were not available. Based on the overall quality and relevance of the studies reviewed, each conclusion was rated
as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available,
this was noted [21].

Results
Figures 1 and 2 illustrate the results of the primary
search.
Vital signs and chief complaints

Most of the studies that investigated associations

between different vital signs or chief complaints and
mortality after ED arrival were observational cohort studies based on selected, diagnosis-specific, patient groups.

All of the studies were found to have medium quality

and relevance. Only a few studies included all patients
(albeit limited to medical patients) that arrived at the
ED, regardless of diagnosis. Hence, studies of patients
classified as surgical disciplines were generally lacking.
Several studies described compiled scales or indexes for
appraising the severity level of the patients conditions,
but provided no information on the importance of specific vital signs or chief complaints. Hence, little or no
evidence can be found on the association between specific vital signs or reasons for the ED visit and mortality
in the group of general patients presenting in EDs.
Respiratory rate

Only a single study, which described the predictive

importance of respiratory rate, fulfilled the inclusion criteria [22]. The study aimed to assess whether the Rapid
Acute Physiology Score (RAPS) could be used to predict
mortality in nonsurgical patients on ED arrival. It also
aimed to study whether an advanced version of RAPS, i.
e. the Rapid Emergency Medicine Score (REMS), could
yield better predictive information [22].
RAPS was developed for prehospital care and involves
assessing respiratory rate, pulse, blood pressure, and the
Glasgow Coma Scale (GCS). REMS is based on RAPS,

Abstracts identified
through database
seaching
4 185

Articles studied
in full text
89
Articles identified through
other sources
10

Low quality
1

Articles included in systematic

review
4

Medium quality
3

Figure 1 Results of literature search and selection process.

Page 3 of 13

Abstracts excluded
by relevance
4 096

Articles excluded
by relevance,
study design and
non-sufficient
eligibility
95

High quality
0

Farrohknia et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:42
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Abstracts identified
through database
seaching
2 776

Articles studied
in full text
168
Articles identified through
other sources
1

Low quality
11

Articles included in systematic

review
20

Medium quality
9

Page 4 of 13

Abstracts excluded
by relevance
2 608

Articles excluded
by relevance,
study design and
non-sufficient
eligibility
149

High quality
0

Figure 2 Results of literature search and selection process regarding reliability (10 articles), and validity (10 articles) of triage scales.
One article studied both reliability and validity and was rated differently due to the studied endpoint, low quality regarding reliability and medium
quality regarding validity.

but also assesses oxygen saturation, body temperature,

and age. In total, 11 751 patients were studied prospectively after arrival at the ED of a university hospital in Sweden. Respiratory rate was found to be a
significant predictor of mortality during the hospital
stay. A decrease of one step on the RAPS scale was
found to nearly double the risk of mortality within 30
days (Table 1).
Oxygen saturation in blood

Two studies used RAPS and REMS to predict acute

mortality after ED arrival and specifically studied the
predictive importance of saturation [22,23]. Oxygen
saturation was found to be one of the three variables,
along with age and level of consciousness, that best predicted mortality during hospitalization.
Pulse

One study investigated the importance of assessing pulse

in the ED as a means to predict mortality during the
hospital stay.
The study, which was conducted in Sweden [22],
showed a significant association between the pulse on
arrival to the ED and mortality during the hospital stay

in a group of 11 751 patients receiving care for nonsurgical disorders. With a decrease of one step on the
RAPS scale, 67% of the patients showed an increased
risk of mortality within 30 days.
Level of consciousness

The Swedish study (described above) also investigated

the association between acute mortality and the level of
consciousness on arrival at the ED [22]. Another study
used the same methods mentioned above, i.e. RAPS and
REMS [23], to analyze 5583 patients that had called the
emergency phone number and were classified as urgent.
The study showed that level of consciousness was one of
three variables (age and saturation being the other two)
that best predicted mortality during the hospital stay.
Another study analyzed 986 stroke patients on ED arrival. Impaired level of consciousness appeared to be the
best predictor of mortality during the hospital stay [24].
Blood pressure and body temperature

The importance of blood pressure or body temperature

in assessing the risk of acute mortality after ED arrival
could not be supported by the included studies due to
the lack of scientific evidence.

Farrohknia et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:42
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Page 5 of 13

Table 1 Does assessment of certain vital signs and chief complaints in emergency department triage of adults have an
impact on 30-day or in-hospital mortality?
Author
Year,
reference
Country

Study design Patient characteristics

Sample Female/age Male/
age Inclusion criteria Type
of emergency department

Primary
outcome

Outcome Frequency RR
(relative risk), OR (odds
ratio) P-value, 95% CI
(confidence interval)

Missing data (%)

Study
quality and
relevance
Comments

Goodacre
S et al
2006 [23]
United
Kingdom

Observational
Cohort
Retrospective
database
review

Mortality
in
hospital
during
the stay

Age, Glascow Coma Scale

(GCS) and oxygen saturation
independent predictors of
mortality in multivariate
analysis, blood pressure is not
useful

Rapid Acute Physiology

Score (RAPS - blood
pressure, pulse, GCS, RR,
saturation and temp) in
only 3 624 (64.9%). Missing
in 35.1%

Moderate

Emergency medical
admissions, life threatening
category A emergency calls
N = 5 583
Female: 2 350 (42.3%)
Male: 3 233 (57.7%)
Mean age 63.4 years

Glascow Coma Scale (GCS):

OR 2.10 (95% CI 1.86-2.38) p
< 0.001

Inclusion criteria: Any case

where caller report chest pain,
unconsciousness, not
breathing and patient
admitted to hospital or died in
emergency department (ED)

Age: OR 1.74 (95% CI 1.521.98) p < 0.001

Saturation: OR 1.36 (95% CI
1.13-1.64) p = 0.001

Setting: variables recorded on

ambulance arrival
Olsson T
et al
2004 [22]
Sweden

Observational
cohort
Prospective

Nonsurgical emergency
department (ED) patients
n = 11 751
Female: 51.6%
Male: 48.4%
Mean age 61.9 (SD 20.7)

Mortality
in
hospital,
within 48
hours

Inclusion criteria: Patients

consecutively admitted to the
emergency department (ED)
over 12 months.
Exclusion criteria: Patients
with cardiac arrest that could
not be resuscitated, patients
with more than one parameter
missing.
Setting: 1 200 bed University
hospital ED in Sweden
Han JH et
al 2007
[25]
USA
Singapore

Observational
cohort
Retrospective
database
review
Comparison
patients /
75 years

Suspected acute coronary

syndrome (ACS)
n = 10 126
Female: 5 635
Male: 4 491
Mean age = ?
11.4% 75 years
Inclusion criteria: age 18,
suspected ACS verified by
electrocardiogram (ECG),
cardiac biomarkers, dyspnoea,
light-headedness, dizziness
and weakness.
Exklusion criteria: Interhospital transfer, if missing
data concerning gender, age
or clinical presentation
Setting: 8 emergency
departments (ED) (USA), 1 ED
(Singapore)

Mortality
inhospital/
within 30
days

Acceptable
external
validity
Good/
acceptable
Rapid Emergency Medicine internal
Score (REMS - Blood
validity
pressure, pulse, GCS, RR) in
only 2 215 (39,7%). Missing Age, GCS and
in 60.3%.
saturation
independent
New Score (GCS,
predictors of
saturation, age) in 2 743
mortality.
(49.1%). Missing in 50.9%
Blood
pressure is
not a useful
predictor
Moderate
Good internal
validity

In-hospital mortality 2.4%,

mortality within 48 hours
1.0%.
Predictors for mortality:
Saturation OR: 1.70 (95% CI:
1.36-2.11) p < 0.0001
Respiratory frequency OR:
1.93 (95% CI: 1.37-2.72)
p < 0.0002
Pulse frequency OR 1.67
(95% CI 1.36-2.07) p < 0.0002
Coma OR: 1.68 (95% CI:
1.38-2.06) p < 0.0001
Age OR: 1.34 (95% CI:
1.10-1.63) p < 0.004

2.7% in-hospital mortality for

patients age 75 years,
higher 30 day mortality
(Adjusted OR: 2.6, 95% CI:
1.6-4.3)

Missing data for ECG,

symptoms or gender in 1
810 (15.2%)

Low
Convenience
sampleselection bias
Confounders,
such as comorbidity not
described
Acceptable
intern validity

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Page 6 of 13

Table 1 Does assessment of certain vital signs and chief complaints in emergency department triage of adults have an
impact on 30-day or in-hospital mortality? (Continued)
Arboix A
et al
1996
[24]
Spain

Observational
cohort

Stroke
n = 986
Female: 468
Male: 518
Mean age = ?
Inclusion criteria: First-ever
stroke, admitted to hospital.
Setting: Department of
neurology, university hospital

Mortality Overall mortality 16.3%.

Not stated
in-hospital Age OR: 1.05 (95% CI:
1.03-1.07), previous or
concomitant Pathologic
conditions OR: 1.83 (95% CI:
1.19-2.82)
Deteriorated level of
Consciousness OR: 11.70
(95% CI: 7.70-17.77)
Vomiting OR: 2.18 (95% CI:
1.20-3.94)
Cranial nerve palsy OR: 2.61
(95% CI: 1.34-5.09)
Seizures OR: 5.18 (95% CI:
1.70-15.77) and
Limb weakness OR: 3.79
(95% CI: 1.96-7.32) were
independent prognostic
factors of in-hospital mortality

Moderate

Chief complaints

Interrater agreement of triage scales (reliability)

Studies describing the association between different

chief complaints and acute mortality were found to be
lacking.

All 11 articles that were found to answer the question concerning reliability of triage scales and met the defined
inclusion criteria were observational studies. They
addressed reliability of the ATS [26], CTAS (including
eTriage) [19,27-30], MTS [31], SRTS [6], and two locally
produced scales without names [8,32] (Table 3). Based on
the quality review, 9 articles [6,8,19,26-31] were found to
be of low and 1 [32] of medium quality. One article was
excluded due to deficient quality resulting from high internal dropout [16]. Deficient external validity was the major
reason for the low- and medium-quality ratings of the studies. Selection of patients and triage nurses were both
found to be irrelevant or insufficiently described. Hence,
10 articles remained as a basis for the conclusions.
The scientific evidence was found to be insufficient to
assess the reliability of ATS, CTAS, MTS, SRTS and the

Age

Three of the studies described above showed that the

higher the patients age, the greater the risk of death
within 30 days of hospital care following ED arrival
[22-24]. The results showed an increase in mortality of
5% per year. Furthermore, one study showed that older
patients (above 75 years of age) with symptoms of coronary heart disease had a greater risk of death within 30
days after arrival at the ED compared to younger
patients with the same symptoms [25] (Table 1).
Based on the studies described above, Table 2 summarizes assessments and comments regarding the level
of scientific evidence.

Table 2 Appraisal of scientific evidence according to GRADE - Association between vital signs/chief complaints and
acute mortality after arrival at the emergency department.
Effect measure (endpoint)

No. Patients (no.

Studies) Reference

Effect (OR,
odds ratio*)

Scientific
evidence

Comments

Respiratory rate predicts 30-day mortality

11 751
1 study [22]

1.9

Insufficient

Only one study (-1)

Oxygen saturation predicts 48-hour mortality or 17 334

in-hospital mortality
2 studies [22,23]

1.4
1.7

Limited

Pulse predicts 30-day mortality

11 751
1 study [22]

1.7

Insufficient

Level of consciousness predicts 48-hour

mortality or in-hospital mortality

18 320
3 studies [22-24]

2.1
1.7
11.7

Limited

Age predicts 30-day mortality

28 446
4 studies [22-25]

1.7
1.3
2.6
1.1

Moderate

Only one study (-1)

Upgrading due to effect size and

dose-response effect (+1)

All studies are observational.

* OR indicates each step of change in RAPS (Rapid Acute Physiology Score) or REMS (Rapid Emergency Medicine Score).

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Page 7 of 13

Table 3 Reliability of triage scales

Author Year,
reference
Country

Triage Patient characteristics: Age

system Gender Triageur: Amount,
profession

Results: -values,
percentage agreement
(PA)/triage level

Drop
out (%)

Study quality and relevance

Considine J
et al
2000, [26]
Australia

ATS

Triage level:
1: 59.7% PA
2: 58% PA
3: 79% PA
4: 54.8% PA
5: 38.7% PA

0%

Low

Dong S et al
2006, [28]
Canada

ETriage
(CTAS)

569 patients
49.4 years
51 % male
Unknown amount of RNs

0.40 (unweighted )
Triage level:
1: 62.5% PA
2: 49.5% PA
3: 59.7% PA
4: 68.5% PA
5: 43.5% PA

1%

Dong S et al
2005, [29]
Canada

CTAS/
eTriage

693 patients
48 years
49 % male
73 RNs

0.202 (unweighted )
Triage level:
1: 50% PA
2: 9% PA
3: 53.5% PA
4: 73.3% PA
5: 7.2% PA

4%

Manos D et al
2002, [30]
Canada

CTAS

42 scenarios
5 BLS
5 ALS
5 RNs
5 Drs

0.77 overall (weighted )

BLS: 0.76 (weighted )
ALS: 0.73 (weighted )
RNs: 0.80 (weighted )
Drs: 0.82 (weighted )

0.2%

10 scenarios
31 RNs

External validity is uncertain, internal validity is

good while sample size is of uncertain
adequacy
Low
External validity can not be assessed, internal
validity is excellent while sample size is of
uncertain adequacy

Low
External validity can not be assessed, internal
validity is excellent while sample size is of
uncertain adequacy

Low
External validity can not be assessed, internal
validity is acceptable while sample size is of
uncertain adequacy

Triage level:
1: 78% PA
2: 49% PA
3: 37% PA
4: 41% PA
5: 49% PA
Beveridge R
et al
1999, [27]
Canada

CTAS

Gransson K
et al
2005, [19]
Sweden

CTAS

50 scenarios
10 RNs
10 Drs

0.80 overall (weighted )

0.84 RNs (weighted )
0.83 Drs (weighted )

15%

External validity can not be assessed, internal

validity is acceptable while sample size is of
uncertain adequacy

Weighted  / triage level

(RNs):
Triage level:
1: 0.73
2: 0.52
3: 0.57
4: 0.55
5: 0.66
18 scenarios
423 RNs

van der Wulp I MTS

et al
2008, [31]
The
Netherlands

50 scenarios
55 RNs

Maningas P
et al
2006, [6]
USA

423 patients
29.7 years
44% male
16 RN pairs

SRTS

Low

0.46 (unweighted )
Triage level:
1: 85.4% PA
2: 39.5% PA
3: 34.9% PA
4: 32.1% PA
5: 65.1% PA

0.8%

0.48 (unweighted )
Triage level:
2: 9.8% PA
3: 35.5% PA
4: 22% PA

7.5-35.7% Low

0.87 (weighted )
Triage level:
1: 85.7% PA
2: 86.7% PA
3: 86.8% PA
4: 93.9% PA
5: 74.2% PA

Low
External validity can not be assessed, internal
validity is acceptable while sample size is of
uncertain adequacy

External validity is uncertain, internal validity is

good while sample size is of uncertain
adequacy
Low
External validity can not be assessed, internal
validity is good while sample size is of uncertain
adequacy

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Page 8 of 13

Table 3 Reliability of triage scales (Continued)

Rutschmann
OT et al
2006, [8]
Switzerland

4-tier
system

22 patient scenarios
45 RNs
8 Drs

RNs: 0.40 (weighted )

Drs: 0.28 (weighted )

4%
0%

External validity is uncertain, internal validity is

excellent while sample size is of uncertain
adequacy

Triage level:
1: 61% PA
2: 49.6% PA
3: 74.2% PA
4: 75.5% PA

Brillman J et al 4-tier
1996, [32]
system
USA

5 123 patients
64% < 35 years
54% male
Unknown amount of RNs and
Drs

Low

0.45 (unknown type of )

Triage level:
1: 0.13% PA
2: 5.2% PA
3: 37.9% PA
4: 24.6% PA

10%

Moderate
External validity is clear, internal validity is good
while sample size is of uncertain adequacy

ATS = Australasian Triage Scale; CTAS = Canadian Emergency Department Triage and Acuity Scale; MTS = Manchester Triage Scale; SRTS = Soterion Rapid Triage
Scale; RNs = registered nurses; Drs = doctors; BLS = Basic Life Support; ALS = Advanced Life Support

Swiss scale (Table 4). However, limited scientific evidence was found in assessing the reproducibility of the
Brillman scale (North America) as having moderate
interrater agreement.
Validity of triage scales regarding acute mortality and
hospital admission rates
Mortality

None of the studies reported on hospital admission rates

adjusted for age and gender or mortality (Table 5). Since
previous studies have shown that age is one of the major
predictors of hospital mortality [33,34] the scientific evidence was found to be insufficient to asses the validity
of the triage scales ATS, CTAS, and Medical Emergency
Triage and Treatment System (METTS) (Table 6). However, safety as measured by hospital mortality in patients
graded as low risk (triage levels 4-5/green-blue) by the
triage systems may be regarded as one aspect of validity.
When assessing the above-mentioned triage scales level
of validity as regards mortality at the lowest triage levels
only (levels 4-5/green-blue), the quality and relevance of

the studies were found to be moderate. Hence, scientific

evidence is limited.
Hospital admission rates in patients triaged as non-acute

Nine studies reported on admission rates for the ESI,

ATS, and SRTS triage scales (Table 7). The studies
showed a range between 0.0% and 17.0% at level 5, the
lowest triage level [6,16,35-41]. A range was also
observed in the age panorama (mean ages between 30
and 47 years) and in hospital admission rates at triage
level 4 (3%-33%): 18% to 33% for ATS, 6% to 10% for
ESI, and 3% for SRTS.
Seven of these studies were found to be of moderate
and two of low quality and relevance, and the scientific
evidence for validity of admission rates for patients in
the lowest triage levels (levels 4-5/green-blue) was found
to be limited (Table 8).

Discussion
Our systematic review shows that when adjudicated by
standard criteria for study quality and scientific evidence, the triage scales used in EDs are supported, at

Table 4 Appraisal of scientific evidence (according to GRADE) - Reliability of triage scales

Effect measure
(endpoint)

Triage
scale

No. Patients/cases (no. Agreement (Kappa/

Studies)
percent)

Scientific
evidence

Comments

Reliability

ATS

10 cases
(1 study) [26]

38.7%-79%

Insufficient

Reduction for study quality and imprecise

data (-1)

CTAS

1372 patients/cases
(5 studies) [19,27-30]

0.20-0.84
(-value)

Insufficient

Reduction for study quality and heterogeneity

of results (-1)

MTS

50 cases
(1 study) [31]

0.48 (-value)

Insufficient

Reduction for study quality and imprecise

data (-1)

SRTS

423 patients
(1 study) [6]

0.87 (-value)

Insufficient

Reduction for study quality and uncertainty of

transferability (-1)

Rutschmann 22 cases
(1 study) [8]

0.28-0.40
(-value)

Insufficient

Reduction for study quality (-1)

Brillman

0.45 (-value)

Limited

All studies are observational.

5123 patients
(1 study) [32]

Farrohknia et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:42
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Page 9 of 13

Table 5 Studies on how the assessment of the urgency of need to see a physician according to different triage
systems could predict hospital mortality
Author Year,
reference Country

Triage
system

Patient
characteristics: Age
Gender

Outcome

Dong SL et al
2007, [43]
Canada

ECTAS

29 346 patients
47 years
48% female

Mortality in Triage level:

ED
1: 22%
2: 0.22%
3: 0.031%
4: 0.018%
5: 0%
OR 664 (357-1233),
1 vs 2-5

Dent A et al
1999, [35]

ATS

42 778 patients
Age & sex not given

In-hospital
mortality

Triage level:
1: 16%
2: 5%
3: 2%
4: 1%
5: 0.1%
p < 0.0001

Moderate

Widgren BR et al
2008, [10]
Sweden

METTS

8 695 patients
65 years
45% female

In-hospital
mortality

Triage level:
1: 14%
2: 6%
3: 3%
4: 3%
5: 0.5%
p < 0.001

- Only patients admitted to Moderate

hospital evaluated

Doherty SR et al
2003, [36]

ATS

84 802 patients
Age & sex not given

24 hours
mortality

Triage level:
1: 12%
2: 2.1%
3: 1.0%
4. 0.3%
5: 0.03%
p < 0.001

- Consecutive patients

Results (Mortality
Remarks
frequency per triage level)

Study quality
and relevance

- Low number of fatalities

(70 cases)

Moderate

Moderate

Mortality figures (%) are shown for each triage level for patients admitted to a hospital emergency department.
CTAS = Canadian Emergency Department Triage and Acuity Scale; ATS = Australian Triage Scale; METTS = Medical Emergency Triage and Treatment System

best, by limited evidence. Often, the evidence is weaker,

not above insufficient by the GRADE criteria. The ability
of the individual vital signs included in the different
scales to predict outcome has seldom, or never, been
studied in the ED setting. The scientific evidence for
assessing interrater agreement (reproducibility) was limited for one triage scale (Brillman) whereas it was insufficient or lacking for all other scales. Two of the scales
(CTAS and ATS) offered limited scientific evidence, and
the scientific evidence for one scale (METTS) was insufficient to assess the risk of early death or hospitalization

in patients assigned to the two lowest triage levels in 5level scales; the studies showed the risk of death to be
low, but a need for inpatient care was not excluded
(about 5% hospital admission rate on average). Studies
on validity of the triage scales across all levels, i.e. their
ability to distinguish the urgency in patients assigned
the five different levels, were generally of low quality.
Consequently, evidence was insufficient to assess the
validity of the scales.
As none of the studies reported on mortality rates
adjusted for differences in age and gender between the

Table 6 Appraisal of scientific evidence (according to GRADE) - Validity of 5-level triage scales measured by acute
mortality
Effect measure
(endpoint)

Triage
scale

No. Patients (no.

Studies)

Mortality at triage level 5

(percent)

Scientific
evidence

Comments

Patient mortality

CTAS

29 346
(1 study) [43]

0%

Limited

Only one study, but large

population

ATS

127 079
(2 studies) [35,36]

0.03%-0.1%

Limited

METTS

8695
(1 study) [10]

0.5%

Insufficient

All the studies are observational

Reduction for study quality (-1)

Farrohknia et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:42
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Page 10 of 13

Table 7 Studies on how the assessment of the urgency of need to see a physician according to different triage
systems could predict hospitalization
Author Year,
reference Country

Triage
system

Patient
characteristics: Age
Gender

Outcome

Results (Hospital admission

frequency per triage level)

Van Gerven R et al
2001, [39]
The Netherlands

ATS

3 650 patients,
Age & sex not given

Hospital
admission

Triage level:
1: 85%
2: 71%
3: 48%
4: 18%
5: 17%
p < 0.0001

Moderate

Chi CH et al
2006, [16]
Taiwan

ESI2

3 172 patients
47 years
47% female

Hospital
admission

Triage level:
1: 96%
2: 47%
3: 31%
4: 7%
5: 7%
p < 0.0001

- ESI scored in
Moderate
retrospect
- Unclear
inclusion criteria

Wuerz RC et al
2000, [40]
USA

ESI

493 patients
40 years
52% female

Hospital
admission

Triage level:
1: 92%
2: 61%
3: 36%
4: 10%
5: 0 %
p < 0.0001

- Unclear
Low
inclusion criteria

Dent A et al
1999, [35]

ATS

42 778 patients
Age & sex not given

Hospital
admission

Triage level:
1: 83%
2: 69%
3: 49%
4: 33%
5: 9%
p < 0.0001

Eitel DR et al
2003, [37]
USA

ESI2

1 042 patients
7 different EDs
43 years
47% female

Hospital
admission

Triage level:
1: 83%
2: 67%
3: 42%
4: 8%
5: 4%
p < 0.001

- Not
consecutive
patients

Moderate

Tanabe P et al
2004, [38]
USA

ESI3

403 patients
45 years
49% female

Hospital
admission

Triage level:
1: 80%
2: 73%
3: 51%
4: 6%
5: 5%
p < 0.001

- Not
consecutive
patients
- Retrospective
triage

Low

Wuerz RC et al
2001b, [41]
USA

ESI

8 251 patients
Age & sex not given

Hospital
admission

Triage level:
1: 92%
2: 65%
3: 35%
4: 6%
5: 2%
p < 0.001

- consecutive
patients

Moderate

Doherty S et al
2003, [36]

ATS

84 802 patients
Age & sex not given

Hospital
admission

Triage level:
1: 79%
2: 60%
3: 41%
4: 18%
5: 3.1%
p < 0.001

- consecutive
patients

Moderate

Maningas PA et al
2006, [6]

SRTS

33 850 patients
Age 30, 56% female

Hospital
admission

Triage level:
1: 43%
2: 30%
3: 13%
4: 3.0%
5: 1.4%
p < 0.0001

- consecutive
patients

Moderate

Hospitalization figures (%) are shown for each triage level for patients admitted to a hospital emergency department.
ATS = Australian Triage Scale; ESI = Emergency Severity Index; SRTS = Soterion Rapid Triage Scale.

Comments

Study quality and

relevance:

Moderate

Farrohknia et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:42
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Page 11 of 13

Table 8 Appraisal of scientific evidence (according to GRADE) - Safety of 5-level triage scales as measured by
hospitalisation rates in patients at triage level 5.
Effect measure (endpoint)

Triage
scale

Patient safety related to hospital ATS

admission

No. patients (no.

studies)

Hospitalization rate at triage level Scientific

5 (percent)
evidence

131 230
3.1%-17%
(3 studies) [35,36,39]

Limited

ESI

13 361
(5 studies)
[16,37,38,40,41]

0%-7%

Limited

SRTS

33 850
(1 study) [6]

1.4%

Limited

Comments

Only one study, but many

patients

All studies are observational.

triage levels, we could not evaluate the validity of the

triage scales across all triage levels as regards the risk of
early death. To estimate the safety of the scales, we studied early death among patients assigned to the lowest
triage levels (green and blue/4-5). Two triage scales
(ATS and CTAS) offered limited scientific evidence for
assessing safety. In both scales, the patients assigned to
the two lowest triage levels had a very low risk of dying
within 24 hours after triage. Hence, in this respect, the
scales are safe to use. Scientific evidence for METTS,
the newly developed Swedish triage scale, was found to
be insufficient to assess safety. Since the study recorded
the risk of dying during the in-hospital stay, mortality
was higher than in the studies on ATS and CTAS.
In using the need of hospitalization as a measure of
safety, the situation was found to be more complex.
Again, none of the studies reported on hospital admission rates adjusted for age and gender, so we could not
evaluate the validity of the triage scales across all triage
levels. However, on average, about 5% (in some studies
up to 17%) of patients in the lowest (4-5/green-blue)
triage levels in ATS, ESI, and SRTS were reported to be
admitted as inpatients. The variations were wide not only
between different triage scales, but also between studies
using the same scales. This indicates differences between
the studies in (a) patient populations in the ED, (b) access
to hospital beds, (c) hospital admission policies and traditions, and/or (d) inaccurate triage decisions (i.e. patients
were rated as less urgent than their actual urgency).
No definitive conclusions could be drawn regarding
which of the scales was the safest as measured by the
need of hospitalization. Hence, we suggest that none of
the scales be used in referral of patients in the lowest
triage levels (4-5/green-blue), e.g. to primary care, without further medical examination in the ED.
New diagnostic tests typically need to meet rigid criteria before they can be accepted for widespread use.
These criteria include documentation on precision. For
non-laboratory tests, interrater agreement (reliability) is
a key precision issue. Our review shows that most triage
scales present insufficient scientific evidence for

assessing interrater agreement. The study designs used

to estimate interrater agreement have often been suboptimal. Most of the studies are based on fictitious cases
rather than on authentic patients in real-life settings.
The value of the studies as regards interrater agreement
is also compromised by the fact that the mean age of
patients assessed has either been low (as low as 30
years) or unreported. The generalizability to real-life ED
patients must therefore be questioned.
All 5-level triage scales present insufficient evidence
on interrater variability. The few studies that have been
published (most of low quality) have reported widely
divergent interrater agreement, with kappa values ranging from 0.2 (slight agreement) to 0.9 (almost perfect).
Only a single study [32] presented limited scientific evidence. This was a 4-grade scale reporting a kappa value
of 0.45, a value usually considered to be in the moderate
agreement range [42]. It is evident that inter-observer
agreement in triage scales must be documented in
greater detail, and, if low, actions must be taken to
reduce variability.
The literature shows variations in the vital signs and
chief complaints applied in triage scales. It is unclear
whether the selected vital signs are the best at distinguishing different risk groups. Further, evidence supporting the selected thresholds for continuous variables
is deficient. The inclusion criteria for this systematic literature review place considerable emphasis on relevance.
Triage scales are intended to be used in EDs irrespective
of specific symptoms or disease. Hence, only studies of
unselected patient populations in ED settings were
included, greatly limiting the number of studies on the
ability of individual vital signs to predict outcome. Our
literature search revealed that many more studies had
been performed in intensive care units, or soon after
hospital admission.
Regarding specific vital signs, limited scientific evidence supports the use of oxygen saturation and consciousness level as predictors of mortality early after
triage. However, scientific evidence was found to be
insufficient as regards respiration and pulse, blood

Farrohknia et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:42
http://www.sjtrem.com/content/19/1/42

pressure, and body temperature. Hence, it remains

unclear whether the selected vital signs are the best
ones to use in distinguishing different risk groups. Moderate scientific evidence indicated age as a predictor of
mortality early after triage, yet most triage scales do not
take age into account.
MTS and eCTAS include the chief complaint leading
to the ED visit, but we did not find any studies that analyzed which of the chief complaints are important predictors of mortality early after triage. It appears likely
that in the construction of triage scales, much of the
information was deduced from studies performed in settings other than EDs.
Strengths and limitations

The strength of this review of the scientific literature on

triage in the ED lies in its systematic approach. Our
search for relevant literature has been meticulous; the
quality of the included studies has been evaluated in a
uniform manner; and the level of evidence has been summarized using the GRADE methodology developed under
the auspices of the World Health Organization [21].
Our review is limited to ED triage in adult patients in
somatic care. However, EDs are only part of a continuum of services for acutely ill and injured patients.
Studies are also needed in other aspects along the continuum of care, e.g. prehospital, psychiatric, and pediatric
triage. Other limitations are ascribed to the volume and
quality of the scientific literature available. Since all studies were observational, none of the evidence came
from randomized controlled trials, the gold standard
for evaluating new methods. As none of the studies met
the standards for high quality, we included studies of
low and moderate quality in our review in accordance
with the creed in evidence based medicine to use the
best available scientific evidence. Low study quality
affected the GRADE rating and was a reason why scientific evidence was rated as insufficient or limited for so
many aspects of so many scales.

Conclusions
This systematic literature review reveals shortcomings in
the scientific evidence on which presently available
triage scales are based. Stronger scientific evidence is
needed to determine which of the vital signs and chief
complaints have the greatest prognostic value in triage.
Interrater agreement (reliability), validity, and safety of
triage scales need to be investigated further, and headto-head comparisons are needed to determine whether
any of the scales have advantages over others.
Limitations
This review was confined to ED triage scales for adult
ED patients with non-psychiatric illnesses or injuries. In

Page 12 of 13

the absence of an internationally agreed outcome measure for ED triage scale validity, the proxy variables hospital admission and mortality were used in the current
study. These proxy variables have limitations with
regards to ED triage scale validity as the variables may
be affected by events occurring after the triage assessment. Further, comparison between ED triage scales
need to be done with caution as there may be contextual differences influencing the result.
Author details
1
The Swedish Council for Health Technology Assessment and Dep of
Medical Sciences, Uppsala University Hospital, Uppsala, Sweden. 2Dept of
Clinical Science and Education and Section of Emergency Medicine,
Sdersjukhuset (Stockholm South General Hospital) Stockholm, Sweden.
3
School of Health and Social Studies, Dalarna University, Falun, Sweden.
4
Dept of Medicine, Uppsala University Hospital, Uppsala, Sweden. 5Dept of
Emergency Medicine, Helsingborg Hospital, Helsingborg, Sweden. 6Dept of
Orthopedics, Uppsala University Hospital, Uppsala, Sweden. 7Dept of Public
Health and Clinical Medicine, University Hospital, Ume, Sweden. 8Dept of
Emergency Medicine, Karolinska University Hospital, Solna, Sweden. 9Dept of
Medicine, Karolinska Institutet, Solna, Sweden.
Authors contributions
All authors contributed to study concept and design, and acquisition,
analysis, and interpretation of the data. Finally all authors read and approved
the submitted manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 11 April 2011 Accepted: 30 June 2011
Published: 30 June 2011
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doi:10.1186/1757-7241-19-42
Cite this article as: Farrohknia et al.: Emergency Department Triage
Scales and Their Components: A Systematic Review of the Scientific
Evidence. Scandinavian Journal of Trauma, Resuscitation and Emergency
Medicine 2011 19:42.

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